Do oral nutritional supplements effectively reduce malnutrition or its adverse outcomes in older people with frailty?
Authors: Jane Murphy
Journal: The Lancet Healthy Longevity (2022)

Although malnutrition and frailty are distinct conditions, they are related syndromes with notable overlap, each one aggravating the other with similar adverse functional and health outcomes. For example, unintended weight loss, a characteristic of malnutrition, is associated with the loss of skeletal muscle mass and function with age and is a key risk factor for developing frailty.1Fougère B Morley JE Editorial: weight loss is a major cause of frailty.J Nutr Health Aging. 2017; 21: 933-935Crossref PubMed Scopus (20) Google Scholar Estimates of malnutrition prevalence and malnutrition risk in older people with frailty varies widely. Among malnourished older adults, prevalence of frailty ranged between 27%2Wei K Nyunt MSZ Gao Q Wee SL Ng TP Frailty and malnutrition: related and distinct syndrome prevalence and association among community-dwelling older adults: Singapore longitudinal ageing studies.J Am Med Dir Assoc. 2017; 18: 1019-1028Summary Full Text Full Text PDF PubMed Scopus (108) Google Scholar and 68%,3Verlaan S Ligthart-Melis GC Wijers SLJ Cederholm T Maier AB de van der Schueren MAE High prevalence of physical frailty among community-dwelling malnourished older adults—a systematic review and meta-analysis.J Am Med Dir Assoc. 2017; 18: 374-382Summary Full Text Full Text PDF PubMed Scopus (153) Google Scholar and for older people with frailty, prevalence of malnutrition ranged between 10%3Verlaan S Ligthart-Melis GC Wijers SLJ Cederholm T Maier AB de van der Schueren MAE High prevalence of physical frailty among community-dwelling malnourished older adults—a systematic review and meta-analysis.J Am Med Dir Assoc. 2017; 18: 374-382Summary Full Text Full Text PDF PubMed Scopus (153) Google Scholar and 16%, increasing to 66% if the risk of malnutrition was included.2Wei K Nyunt MSZ Gao Q Wee SL Ng TP Frailty and malnutrition: related and distinct syndrome prevalence and association among community-dwelling older adults: Singapore longitudinal ageing studies.J Am Med Dir Assoc. 2017; 18: 1019-1028Summary Full Text Full Text PDF PubMed Scopus (108) Google Scholar The variation in prevalence is probably a result of the type of population studied and inconsistencies in measuring frailty, as it is difficult to quantify and diagnose. Although studies have been conducted mostly in community-dwelling older adults, there is a need to better understand the overlap between malnutrition and frailty in hospitalised older adults and those at high risk of long-term diseases.4Laur CV McNicholl T Valaitis R Keller HH Malnutrition or frailty? Overlap and evidence gaps in the diagnosis and treatment of frailty and malnutrition.Appl Physiol Nutr Metab. 2017; 42: 449-458Crossref PubMed Scopus (90) Google Scholar Malnutrition is a complex problem and a substantial threat to our health, especially as we age. Although much focus has been on illness and disease, growing numbers of older people are reporting food insecurities, thereby increasing malnutrition risk; these numbers have been exacerbated since the COVID-19 pandemic, as a result of the psychological consequences of social isolation, affecting appetite and interest in eating, thus reducing food intake.5Murphy JL Prevention, identification and management of malnutrition in older people in the community.Nursing Standard. 2022; (published online July 4.)https://doi.org/10.7748/ns.2022.e11891Crossref PubMed Google Scholar As such, the impact of COVID-19, and now the cost of living crisis, is making the need more important than ever. It is not surprising that malnutrition comes at significant cost across both health and care systems. The cost of malnutrition in the UK exceeds GBP£23·5 million per year, and it costs three times more to treat someone who is malnourished than someone who is not malnourished(£7408 vs £2155).6Elia M The cost of malnutrition in England and potential cost savings from nutritional interventions (short version). Malnutrition Action Group of BAPEN and the National Institute for Health Research Southampton Biomedical Research Centre, Southampton2015Google Scholar Current UK guidance focusses on treating malnutrition to provide oral or artificial nutrition support, where indicated, including dietary advice, food fortification or prescribed oral nutritional supplements (ONS).7NICENutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical guideline number 32. National Institute for Health and Care Excellence, London2017Google Scholar However, there is little evidence on whether ONS (with or without other nutritional support) are effective in reducing malnutrition specifically for older people with frailty. Given this background context, the systematic review and meta-analysis of Katie Thomson and colleagues8Thomson KH Rice S Arisa O et al.Clinical effectiveness and cost-effectiveness of oral nutritional supplements in frail older people who are malnourished or at risk for malnutrition: a systematic review and meta-analysis.Lancet Health Longev. 2022; (published online Sept 15.)https://doi.org/10.1016/S2666-7568(22)00171-4Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar in The Lancet Health Longevity is timely and important for our growing ageing population who are at high risk of adverse outcomes from both malnutrition and frailty. Their assessment of clinical effectiveness, cost-effectiveness, and acceptability or adherence of ONS in older adults (≥65 years) with frailty who were either malnourished or at risk of malnutrition included 11 randomised controlled trials and 822 participants. Six of the selected studies were fully, or part-funded by industry. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessments suggested that the evidence of very low-certainty. ONS showed a slightly positive effect on energy (kcal) intake (standardised mean difference 1·02 [95% CI 0·15 to 1·88]; I2=87%; four studies), protein intake (standardised mean difference 1·67 [–0·03 to 3·37; I2=97%; four studies), and mobility y (mean difference 0·03 [0·02 to 0·04]; I2=0%; four studies), compared with standard care, with no consensus of ONS on quality of life. Only one economic evaluation was included showing cost-effectiveness of ONS, which was conducted in care homes. Although the findings of the study by Thomson and colleagues8Thomson KH Rice S Arisa O et al.Clinical effectiveness and cost-effectiveness of oral nutritional supplements in frail older people who are malnourished or at risk for malnutrition: a systematic review and meta-analysis.Lancet Health Longev. 2022; (published online Sept 15.)https://doi.org/10.1016/S2666-7568(22)00171-4Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar are not able to firmly answer the question whether ONS effectively reduce malnutrition or its adverse outcomes in older people with frailty, their contribution is important because it raises the concern of both malnutrition and frailty in older people and gaps in the evidence base. The authors recognise the small evidence base, studies of small sample size, limited evidence on health-care resources, and interventions of short duration, thus stressing the need for high-quality, well designed, and appropriately powered, robust studies, independently funded across a range of settings. Additionally, Thomson and colleagues highlight research comparing ONS with other dietary interventions, including food fortification and dietary advice. Attention is needed on studies that address the cost-effectiveness of ONS for frail older people and, given the paucity of qualitative studies, to understand acceptability of ONS in older people in hospitals and living in community settings. However, given the overlap in the prevalence of malnutrition and frailty, well designed complex interventions that combine ONS and physical activity also warrant investigation as a way forward for managing both conditions.1Fougère B Morley JE Editorial: weight loss is a major cause of frailty.J Nutr Health Aging. 2017; 21: 933-935Crossref PubMed Scopus (20) Google Scholar Better defined inclusion criteria for the severity of malnutrition and frailty are needed, using standard assessment tools validated for the relevant population and stage and treatment details of the condition, which should be clearly described in a range of health and care settings. A more consistent approach to define and describe the quality of different interventions with better reporting are needed, together with consideration of behaviour change strategies to target the intervention. Outcomes need to be measured using tools, validated for the relevant population and at consistent time points, and better reflect practice.9Baldwin C de van der Schueren MA Kruizenga HM Weekes CE Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults.Cochrane Database Syst Rev. 2021; 12CD002008PubMed Google Scholar Taken together with the findings of the study by Thomson and colleagues,8Thomson KH Rice S Arisa O et al.Clinical effectiveness and cost-effectiveness of oral nutritional supplements in frail older people who are malnourished or at risk for malnutrition: a systematic review and meta-analysis.Lancet Health Longev. 2022; (published online Sept 15.)https://doi.org/10.1016/S2666-7568(22)00171-4Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar it is clear that future well conducted research is crucial to improve outcomes for growing diverse populations of older people with malnutrition and frailty, and to inform guidance for clinicians and practitioners who have a key role in managing these conditions across health and social care settings. I declare no competing interests. Effectiveness and cost-effectiveness of oral nutritional supplements in frail older people who are malnourished or at risk of malnutrition: a systematic review and meta-analysisWe found little evidence of ONS reducing malnutrition or its associated adverse outcomes in older people who are frail. High-quality, non-industry-funded, adequately powered studies reporting on short-term and long-term health outcomes, determinants, and participant characteristics are needed. Full-Text PDF Open Access